AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2016 Issue 3; Ask the Editor
Coding from Pathology Report
For inpatient cases, coders are expected to query the physician if there is conflicting information between the medical record final diagnosis and the pathology report. However, if a patient is admitted with a brain mass, the provider notes in the operative report that the mass was removed and the pathology report contains specific information as to the type of tumor (e.g., benign or malignant), can the more specific diagnosis (malignant tumor) be coded based on the pathology report? ...
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Article Overview
This article addresses the relationship between pathology reports, physician documentation, and inpatient coding decisions. It is aimed at coders and compliance staff who work with final diagnoses, operative notes, and diagnostic results. The discussion centers on the general circumstances in which pathology findings may require physician clarification and how ICD-10-CM official guidance frames abnormal findings.
Why This Topic Matters
Pathology reports can contain more specific clinical information than other parts of the record, so coders need to understand when that information can be reflected in the coded record and when clarification is needed. The article helps readers recognize the documentation and guideline context involved in these situations without replacing the need to review the full guidance.
What You Will Learn
- How pathology reports fit into inpatient coding workflows
- How physician documentation and diagnostic reports interact
- How official ICD-10-CM guidance addresses abnormal findings
- When clarification may be relevant in a coding context
Who Should Read This
- Inpatient coders
- Coding auditors
- Clinical documentation integrity staff
- Compliance staff
- Revenue cycle professionals
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